1. APS 2006 Refresher Course Common auto-immune signaling defects; what does gender have to do with it? Denise Faustman, M.D., Ph.D. Director, Immunobiology Laboratory Massachusetts General Hospital Harvard Medical School

2. APS 2006 Refresher Course

3. Autoimmunity Manifests itself as many different diseases –Type I diabetes, Reumaotid arhritis (RA), Crohn’s, Lupus, and about 45 others Autoimmunity tracks in families, but target tissue differs Autoimmune patients often develop additional autoimmune disease Complex and inconclusive genetic picture-twins

4. APS 2006 Refresher Course New Concepts Use of TNF not anti-TNF as a therapy For type I diabetes: regeneration is a method of restoring normal blood sugars in diabetes –Disease removal is essential

5. APS 2006 Refresher Course Anti-TNF therapies: approved drugs for autoimmunity Approvals: Rheumatoid Arthritis(RA), Crohn's, Juvenile Rheumatoid Arthritis, etc Ex: infliximab, adalimumab, entanercept Proven efficacy Side effect: induction of new AI

6. APS 2006 Refresher Course

7. Death Receptors and Autoimmunity BAFF/CD40L FasL LPS/Toll TLR4 FAS TNF R BAFFR/CD40-R NIK TRAF MyD88 Casp8 RAIDD RIP2 RIP IKK NFkB p52/p50-RelA,B NOD1 NOD2 Casp9 FADD TCR Self Antigen with MHC

8. APS 2006 Refresher Course Defects in TNF levels (decreased NF  B activation) in murine autoimmunity NOD mouse - dysregulated NFkB TNF gene polymorphisms Excess TNF-R TNF or it’s induction is therapeutic (JCI 2001; Science 2003) NZB mouse - dysregulated NFkB Induced decrease TNF, accelerated disease TNF is therapeutic BB rat Low TNF production TNF therapeutic

9. APS 2006 Refresher Course Defects in NF-  B in Human Autoimmunity A Frameshift Mutation in NOD2 Associated with Crohn’s Disease, Nature 411: 603 (2001), Nature 411: 599 (2001) Genetic linkage to NFkB modifier IkBa - Multiple Sclerosis, Ulterative colitis Abnormal NF-kB Activity in T Lymphocytes from Patients with Systemic Lupus, Wong, et al., Journal of Immunology 163: 1682 (1999) Abnormalites in T Lymphocytes from diverse human diseases with TNF apoptosis (Faustman lab) Altered CD8 T cell apoptosis and low NFkB in Scleroderma, Kessel et al J Clin Immun Vol 24, 30 (2004) Functional variant of SUMO4, a IkBa modifier with IDDM Nature Genetics 36, 837 (2004) Many genetic papers with linkage of TNF and TNF receptors to autoimmune risk –Met-196to Arg TNFR2 affects TNF apoptosis by impared NFkB signalling (Lupus, Rheumatoid arthritis) JBC 280: 5994 (2005)

10. APS 2006 Refresher Course Destruction of Memory T Cells Defects in NF-  B Activation Rx #2

11. APS 2006 Refresher Course

12. Figure 3A and B 1 2 3 4 5 6 7 8 9 10 11 TNF-  Does Not Induce NF-  B in NOD Mouse TNF-  From Hayashi and Faustman APS 2006 Refresher Course

13. NF-  B Precursor Proteins Are Not Processed Properly in NOD Mouse Figure 2 from Hayashi and Faustman APS 2006 Refresher Course

14. Proteosomes from NOD Mouse Are Missing Key Subunit Figure from Yan et al. APS 2006 Refresher Course

16. Figure 5 A&B from Hayashi & Faustman APS 2006 Refresher Course Nature Medicine 2002; 6:1065.

17. APS 2006 Refresher Course

18. Autoimmunity Target Organ T Cells Defects in tolerance are lineage dependent defects (only certain lymphocytes have the defect, not all lymphocytes)

19. APS 2006 Refresher Course Autoimmunity-Current Rx Target OrganT Cells

20. APS 2006 Refresher Course Autoimmunity-New Rx Target OrganT Cells Rx #1Rx #2 TNF

21. APS 2006 Refresher Course Combination of Approaches Permanent Disease Reversal

22. APS 2006 Refresher Course Combination Treatment Rx #1- Cells w/ MHC class I and self peptide matched Rx #2 TNF-  Induction Diabetic NOD Mouse 40 days 1 injection

23. APS 2006 Refresher Course Figure 3 from Ryu et al. APS 2006 Refresher Course

25. IrradiatedSplenocytes LiveSplenocytes Pancreatic histology after treatment (I) #790#788#744 #699#745#752

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28. Far Side cartoon by Gary Larson of explorers in canoe entering the spleen

29. APS 2006 Refresher Course

30. Hox11 transcription factor Fetal transcription factor for stem cell fate, patterning, neurogenesis Highly conserved in stem cells of sponges, newts Newt regeneration Transfection into ES cells to maintain undifferentiated state Hox11 stem cells in females and males

31. APS 2006 Refresher Course Hox11 expression in spleen of adult mouse but not the pancreas APS 2006 Refresher Course

32. Translation of TNF autoimmune treatment to humans with autoimmunity Next step: Biomarker development Uses: Design of rapid clinical trials dugs